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First-year medical students representing all of the U.S. services filled the National Capital Area Medical Simulation Center (NCAMSC) in Silver Spring, Md., with conversation and laughter as they clustered in conference rooms and hallways. Jamie Roberts, a clinical skills educator, attributed the noise to excitement and nerves as the students waited in anticipation of their first simulated patient interviews.
The students met their patients, played by specially trained actors, in one of 12 exam rooms equipped with live cameras. Instructors and peers observed the interviews from the control room of the clinical skills lab using computers and headphones. Each of the exam rooms was full, while more students waited eagerly in the wings.
The center supports the Uniformed Services University of the Health Sciences and hosts more than 36,000 hours of simulation exercises each year. By graduation, the average USUHS student will have participated in up to 40 different simulations.
In addition to the clinical skills lab, the center is home to a virtual medical environments lab, a surgical simulation lab and a Wide Area Virtual Environment (WAVE). Since opening in April 2000, the center has expanded from 8,000 to 20,000 square feet and held an audience with nearly every other medical school in the country.
"We are one of the most active medical simulation centers in the nation, if not the world," Roberts said. "And we're looking to expand. But, how do we move past what we are doing now, and for more students?"
NCAMSC houses a wide variety of the medical simulation technologies and carries the dual mission of education as well as research and development.
"Our challenge is to keep asking integration questions," Roberts said. "And also, how to make sure the human element doesn't get lost, and keep the consistency of that with the wow of technology."
The military medical community is preparing to embrace medical simulation technology and keep stride with the civilian medical community, and the training and simulation industry stands ready to accept that challenge.
Col. Francisco Espaillat, assistant project manager for medical simulations with the U.S. Army Program Executive Office for Simulation, Training and Instrumentation (PEO STRI), said the Army is looking to take its medical training to the next level. "Medical simulation is going to be the next big thing in simulation as a whole," Espaillat said.
PEO STRI offers the Medical Simulation Training Center (MSTC) as a final training component for combat life savers and a recertification tool for combat medics. The MSTC simulates up to eight casualties from a roadside bomb explosion using high-tech, computerized mannequins. Users face other simulated capabilities such as combat noise and smoke, and must analyze the situation, assess the patients and delegate care.
"DoD estimates the MSTC has saved 1,200-plus lives based on comments from soldiers in live after-action reports," Espaillat said.
PEO STRI's next focus is to advance the use of simulation technology for military doctors and nurses. "We want to train from the hospital to combat and back again," Espaillat said. Immediate technological needs will include untethered mannequins and synthetic surgical environments, he said.
"We will be assessing all the capabilities out there and making sure we get the best," Espaillat said. "We will be challenging the industry to adapt technology for military use. The industry knows this, and they are gearing up."
NETWORKING HOSPITALS
The U.S. Veterans Affairs Department (VA) is developing a strategic plan for a national simulation program called the Simulation Learning Education and Research Network (SimLEARN). The program will ensure simulation spreads to all relevant networks of VA, said David Gaba, associate dean for immersive and simulation-based learning at Stanford University School of Medicine and director of the Patient Simulation Center of Innovation with the VA Palo Alto Health Care System.
"The VA is the largest network of hospitals in the U.S.," he said. "To have a national simulation program for such a large network of hospitals is unprecedented."
Espaillat said PEO STRI is partnering with VA to develop simulation capabilities for the Orlando VA Medical Center, slated to open in August 2012 and selected as the VA's national site for medical simulation training. "The VA is building one of the largest hospitals in the U.S.," Espaillat said, "and it will have one of the largest medical simulation centers in the world."
The VA Palo Alto simulation center will serve as the satellite site for SimLEARN while the national facility is being built, Gaba said. In a 2006 publication, Gaba envisioned medical simulation as an expected part of the health care system rather than an accessory, and predicted medical simulation would have two possible histories by 2025: failure despite early promise or successful integration throughout the fabric of health care.
In 2010, the field has matured from an isolated activity practiced by a few pioneers to be common across many disciplines of health care, he said. Gaba is also editor of Simulation in Healthcare, a journal published by the Society for Simulation in Healthcare. Since its founding in 2004, Gaba said the society has seen its members increase from 400 to more than 2,000.
All initial steps down the road to embed simulation in the fabric of health care have been taken, he said. "It's fairly early in heading down this road. We have a long way to go to replicate what we see in the aviation paradigm."
Guillaume Hervé, president of CAE Healthcare, said the company is focused on accelerating best practices from its 60 years in aviation simulation and adapting them to military medical concepts. Thirty to 40 years ago, when pilots still trained in live aircraft, Hervé said there was a huge push to reduce training errors. "If you look at the track record of aviation, you'll see a tenfold improvement in error rate reductions over the last 20 to 30 years," he said. "A big part of that has been attributed to the use of simulation."
Now, Herve said, the push is toward mandated, simulation-based health care training, and he estimates its global market will exceed $1.5 billion by 2012.
HEALTH CARE AT I/ITSEC
The growing popularity of medical simulation will also be seen at the Interservice/Industry Training, Simulation and Education Conference (I/ITSEC) 2010, Nov. 29-Dec. 2 in Orlando, Fla. New to I/ITSEC this year will be a health care pavilion and more than 90 exhibitors offering health care training, either exclusively or as part of an overall portfolio.
Amy Motko, I/ITSEC 2010 program chair and vice president of Carley Corp., said medical technology is a necessary addition to the training and simulation community. Military and private health care have a great opportunity for collaboration, she said. "Each type can gain from the other to become a much more successful and stronger training program that all medical personnel — military or civilian — will benefit from."
Hervé said CAE hopes to accomplish just that. "Our job is to figure out where our civilian and military medical needs are the same, where we can transpose, where there is a difference," he said. "We're focusing on the military side and making sure we aren't force-fitting a civilian capability on the military."
CAE adapted a bedside ultrasound simulator, called the CAE VIMEDIX echocardiography simulator, for military use. The bedside ultrasound tool clips to a doctor's belt and allows him to generate internal images in the field. Military doctors need to train to look for very specific trauma patterns, such as internal bleeding. CAE adapted its simulator for FAST capabilities — focused assessment with sonogrophy in trauma. "Assessment is the key to identifying very quickly issues around bleeding and trauma that you would see on the battlefield, but wouldn't necessarily see in a city hospital," Hervé said.
CAE is also exploring simulation solutions for minimally invasive surgeries and methods of extracting bullets and shrapnel in combat. "Surgery done in the comfort of a hospital and well prepared is very different form surgery being done in a field hospital," Hervé said.
Strategic Operations, a San Diego-based company that specializes in hyper-realistic training scenarios created with Hollywood special effects, has a patent pending for a Human Worn Partial Task Trainer, also known as the "cut suit." The device fits over a live role player and is anatomically correct with lifelike skin.
"When you open it up you can see the heart pump and the chest expand," Kit Lavell, executive vice president of Strategic Operations, said. "You can suture it, you can staple it." Lavell said the reusable device is primarily intended to train emergency first responders. Although it was designed with combat casualties in mind, Lavell said it has multiple civilian applications as well. "It's for that ‘golden hour' when you have to have somebody stabilized enough to get them to a critical care facility," he said.
VIRTUAL ENVIRONMENTS
Creators of virtual environments are also adapting their capabilities for military medical use. SAIC is considering new ways to use its Online Live Interactive Virtual Environment (OLIVE), a 3-D world that allows users to connect and train just as they would in real life. OLIVE operates over computer networks using a gamelike interface and can be used for managing medical enterprises, such as running an entire casualty management exercise over the course of multiple days. Users can share common data feeds to present sonograms and other clinical imaging data. "Maybe you're in Washington at Walter Reed and I'm in Afghanistan," said David Rees, director of special projects for SAIC. "We can look at the same data and have that collaborative environment."
OLIVE has also been used at the federal and state level to simulate disaster emergency room procedures. OLIVE hasn't been used for complex medical procedures such as surgeries, Rees said, but SAIC is considering the potential. Rees expects the technology to continue growing stronger during the next few years and to see simulation used for more medical procedures such as surgery and remote diagnostics as investment and dialogue progress, he said.
Innovation in Learning, based in Los Altos Hills, Calif., has created a Web-based, 3-D virtual world, CliniSpace, where the virtual humans, DynaPatients, demonstrate two standard scenarios: trauma and infection. DynaPatients are named for their dynamic physiology, similar to that of high-tech mannequins, and each object within CliniSpace is interactive. For example, rather than working off one main menu, if the user clicks on the patient's IV, a menu specific to the IV pops up.
Parvati Dev, president of Innovation, said the core capabilities of trauma and infection are significant applications for military training. "The field scenarios themselves are something that we would have to expand out," she said. "We are considering a combat scenario that we could market to the military."
The U.S. National Capital Area Medical Simulation Center hopes to fully envelope users in a 3-D virtual world upon the completion of its WAVE facility. The prototype version of WAVE features three screens with three potential dynamic environments, including downtown Baghdad, a transport patient helicopter and the inside of an emergency room.
The final version of WAVE will be a barbell shape made of 22 screens and will include the capability to project onto the floor. The warehouse will be equipped with surround sound, cameras, heaters and smoke machines.
Gilbert Muniz, deputy director of NCAMSC, said the appeal of WAVE is its ability to reconfigure. "It can transform from a battlefield to a hospital," he said. "It can go back and forth for as long as the story requires, which is good for long-duration and mass casualty training."
Live actors or high-tech, computerized mannequins can be integrated with WAVE to create mass casualty scenarios. The center has six adult mannequins, two babies and one pediatric mannequin, all manufactured by Laerdal, an international company headquartered in Norway specializing in medical simulation mannequins.
For now, the mannequins are used primarily in the center's surgical simulation lab, which includes a control room with a one-way mirror. They replicate most functions of the human body, including breathing, blinking, vomiting, urinating, bleeding and talking. Jamie Bradshaw, simulation specialist, said instructors can tailor the mannequins for a wide range of custom situations, from trauma and emergency scenarios to exams and procedures.
Feedback and debrief are important parts of the surgical simulation lab, Bradshaw said. "We want students to make their mistakes here."
The center is on the verge of submitting a request for proposals to find a turnkey solution for the necessary infrastructure to create the full version of WAVE, which Muniz said he hopes to have fully operational in late 2011. Once this occurs, the center's ability to integrate training tools will be much more robust. "We're very enthused with the possibility of a hybrid medical simulation experience," Muniz said. "It will be unique to this facility."
NCAMSC has also deployed technology to Iraq from its virtual medical environments lab, which integrates 3-D virtual reality with haptic devices that interact with the user through sense of touch. Alan Liu, director of the virtual medical environments lab, said the center received positive feedback after its cricothyroidotomy (emergency airway) simulator was deployed to Iraq. The device will soon be deployed to Afghanistan for further testing.
"Our purpose is to research and develop capabilities to push out into the field," Liu said. "Medical training really isn't an individual sport. It's more like a team environment."
